Nervous About SNRI Taper
April 14, 2020 7:38 AM   Subscribe

I have had problems with tapering in the past. Now I have to get off an SNRI. Details inside

All the usual disclaimers - you are not my doctor etc.

I don't know if anyone on here has had any experience getting off SNRIs (Pristiq) in particular. I have been put on an SSRI and am tapering of of Pristiq. The doctor wants me to drop from 100 to 50 for a few days and then 25 for a few days and then stop.

I thought that that SNRI's were notoriously tough to get off of and I've ALWAYS had a problem discontinuing meds. I have communicated this to him but he thinks that it is no big deal. Apparently the "selling point" of Pristiq is that it was no more effective over 50MG. No tapering up and tapering down. I don't know if the fact that I am on an SSRI helps with that. I've also heard that the norepineprine doesn't kick in until you exceed 100mg. I believe that he said that NE doesn't cause discontinuation like the serotonin does.

I've dealt with enough doctors in the medical health profession that I am skeptical of everyone.

Thoughts?

Thank you in advance
posted by kbbbo to Health & Fitness (10 answers total)
 
IAMNAD. I am a counselor, but keep in mind, what I have is anecdotal rather than a degree or any competency in pharma.

I would say a healthy skepticism is warranted. Most research is slow to catch up on massive numbers of individual reports of things like SSRI withdrawal, depression due to contraceptive use, weight gain due to asthma inhalers, etc. After 5-10 years of people complaining, research will often validate those complaints. On the far side of all that is the diehard anti-vaxxers, hence HEALTHY skepticism.

What I’ve observed and heard reported is that Paxil, Prozac, and Effexor (SSRI, SSRI, SNRI respectively) are often difficult but not impossible for clients to get off of due to side effects not related to the diagnosis.

Monitor and track symptoms on a 0-10 scale. It can be difficult to separate out side effects from anxiety symptoms, but I still think it’s useful.

I haven’t heard anything about SNRIs as a class personally.
posted by executive_dysfuncti0n at 8:13 AM on April 14


I don't know anything about tapering off Pristiq specifically, but I do know a bit about another SNRI, Effexor (this is what I was prescribed when my insurnace wouldn't cover Pristiq) which can be tough for people to taper off. I heard many times that people who started having bad withdrawal symptoms trying to get off Effexor had good results tapering off by removing a single bead from inside the pill at a time. I've also heard of SNRI withdrawal symptoms being eased by taking a low dose of something like Prozac for a short period of time.

Then again several of my friends had NO ISSUES tapering fairly quickly off Effexor, Cymbalta, etc al., so it's really hard to say whether you will have issues ast all.
posted by shaademaan at 8:28 AM on April 14


There's two aspects to going off a depression medicine: short term withdrawal, and medium term psychological effects. Pristiq has a very short half life of 11 hours it looks like, so that tapering schedule sounds reasonable, if you went off it all at once you would get stronger withdrawal. And because of the half life you can't really do it more gradually with the way the pills are setup. I would expect some withdrawal symptoms at each decrease, but the physical ones will get better quickly. This is what your doctor is talking about when they say it should be fine, and i would believe them.

The part they can't predict, and probably the part that you have had trouble with in the past, is the medium term psychological effects. Its possible the new SSRI you're going on will work immediately, and it's possible it may not work well. If you're like me your brain may be biased to assume it's a complete failure until you suddenly realize a month in that you feel better. I'm assuming the reason you're going off Pristiq is that it doesn't work well for you, so hopefully there won't be much immediate difference, but you should keep track as mentioned. Remember that you're doing this with the hope for a better future, and it won't feel great in the meantime. I wouldn't make a final judgment on the new drug for 6 weeks or so.

Good luck, transitioning psych medicine is always difficult, but from my experience this plan sounds reasonable.
posted by JZig at 8:42 AM on April 14


I had a doctor repeatedly dismiss my concerns about tapering off an SSNRI (not Pristiq, though) and long story short I was right and they were wrong and I ended up having to do the thing where you remove individual beads from the capsules over the course of several months. I think it's pretty much a crapshoot whether you have a good experience or a bad one.

The question is whether you trust your doctor to adjust their thinking if it proves necessary, or whether you think they'll be dismissive even if your experience is bad. In the latter case, ideally you'd find a different doctor. If that isn't an option, then I'd try to put off the tapering until you can build up enough of a supply that you'd be able do the longer process on your own if absolutely necessary. (I think I had about a month's worth and stretched it out by (a) tapering and (b) saving the removed beads and using them in new capsules at the end.)
posted by trig at 9:23 AM on April 14


I'm an emergency physician/medical toxicologist


1) I've also heard that the norepineprine doesn't kick in until you exceed 100mg


SNRI withdrawal is not dose-dependent, so it doesn't matter what the threshold is.

(it's 150mg or higher)

2) DO NOT self-medicate; that means no Prozac or any other drug to try and attenuate withdrawal symptoms. If you're feeling that shitty, talk to your doctor. He or she has several safe pharmaceutical options--valium, buspar, another anti-depressant, one of the newer atypical anti-psychotics--to get you over the hump.
posted by BadgerDoctor at 9:31 AM on April 14


My doc wants me to be on the Zoloft. Not to ease the transition, but to replace the Pristiq

Thank you
posted by kbbbo at 11:13 AM on April 14


I am on Pristiq. Over three years I tapered from 50 to 200mg. While the treatment element worked, the side effects at 200mg were not compatible with everything in my life. Tapering down to 150mg was a week of...not good. I had headaches, the thing my brain does that is not brain zaps, I was excessively angry. After that it was about two weeks of not normal but more manageable. I'm now stable at 150mg and the worst side effects have eased.

There absolutely was a tapering up and down period. I may taper down some more soon, depending on a few things. The very short half life makes the process fairly brutal, which you'll know if you've ever been late with or forgotten a dose.

The usual procedure is long tapering off - a period of weeks or months at each dose, and layering with an SSRI during that period. I didn't layer in another med, because I wasn't coming off it entirely, but I'm pretty sure the first month would have been less of a shit fight if my brain hadn't periodically done the weird zap thing (or in my case more of a bloop).

I'm not a doctor, just a fellow Pristiq user who has covered all the protocols with her dr, and tapered up and down as well.
posted by geek anachronism at 2:25 PM on April 14


Not psychiatrist here but I went off Effexor and it did seem to require a longish bead-by-bead taper over several weeks for me. I don’t know how much of the difficulty was about norepinephrine and how much was just that Effexor has a super short half life. Pristiq’s is still short, but is around twice that of Effexor. (As I understand it, the reason sometimes psychiatrists prescribe single-dose Prozac to people discontinuing Effexor is that the half life of Prozac is long enough that it acts as a natural taper.) That said, the long taper did work for me.

I would say it’s certainly not unreasonable for you to push back and ask for a longer taper. I would not DIY, though, since you’re switching meds and to do that safely your psychiatrist needs to be in the loop about when exactly you last took how much of whatever.
posted by en forme de poire at 4:13 PM on April 14


I'm not a doctor but I've been an intermittent user of antidepressants for most of my adult life. I don't recall any difficulty in tapering off Prozac, Lexapro or Zoloft. Now, Cymbalta (an SSNRI), that was a spicy meatball! I withdrew very, very slowly over a period of nine months going from 60 mg to 5 mg to finally stopping altogether. (I had to open capsules and do the bead counting routine to get that low.) No real withdrawal symptoms until I hit the 10 mg mark when I became an emotional, irritated, hot mess. Add in insomnia and digestive issues for some real fun times.

I'm an anecdote so I went seeking more of me. I found lots of them on Survivingantidepressants.org. Apparently, there are many people who experience withdrawals from all sorts of psychiatric drugs. Despite the wide range of contributors, there was a consistency in the stories. It made me feel better to know I wasn't alone or 'abnormal' in my response. But it can be a rabbit hole of despair so I used it in small doses to look up very specific things, i.e., does magnesium alleviate withdrawal symptoms? is it ok to use antihistamines to help with sleep?

All told, I experienced two pretty miserable months. I feel much, much better now and my sleep is largely normal again. Throughout the experience, my psychiatrist really downplayed the withdrawal symptoms. This was while I was sitting in her office reciting them in detail. So, yeah, there's seems to be this weird disconnect with psychiatrists around withdrawal symptoms.

For the record, I wouldn't hesitate to go back on antidepressants if I needed rescue from an unrelenting depressive episode. But I will never, ever go back on Cymbalta!
posted by MissPitts at 4:35 PM on April 14


I've successfully tapered off Effexor, a very similar compound to Pristiq from my understanding. The first time I tried, I thought I went slow enough over four months, but it turned out that was too fast for me personally. When I tried again a number of years later, it took me 2.5 years to get down to 0, also from a low dose (75mg), and then another full year before I really felt recovered. Mind you, I was taking it for over 25 years.

If you are cross-tapering to another med like it sounds you are, I think it would be easier. Your doc will know best, but I find in most cases docs completely underestimate the withdrawal experience and your skepticism completely warranted. The recent New Yorker article is worth a read if you can find it.

Like MissPitts, I also turned to survivingantidepressants.org as well as some local FB groups to try and help navigate what ended up being a very challenging experience to say the least, and my advice in retrospect would be to try and avoid reading other people's anecdotal experience as much as possible, especially if you are a suggestible person in general. I've avoided talking about my own experience too much here for that reason. Reading the positive stories did give me some ballast and guidance, but it's too easy to get drowned in the rabbit hole of despair, so I highly rate their advice in that regard!

I think the bottom line with all psych meds is how individual the reactions are, and I'd say that this counts just as much for getting off them as it does getting on.

Good luck. Tapering and discontinuing any med is hard work, but from my experience, achievable.
posted by sxtrumpeto at 11:32 PM on April 14


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